Separation Notice form employment

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					                                                                                                              FORM LWC 77 (R 06-09)



                                SEPARATION NOTICE ALLEGING DISQUALIFICATION


1. NAME ______________________________________ 2. SS NO. __________________________________________


3. DATE OF SEPARATION ____________ 4. DATE HIRED____________ 5. DATE LAST WORKED ____________


PLEASE PROVIDE DETAILED EXPLANATION for item checked below. Should this individual file a claim for
unemployment insurance benefits, complete facts will enable this agency to make an equitable decision.


6. REASON FOR LEAVING:                                    7. VACATION, SEVERANCE, DISMISSAL, BONUS,
                                                                     HOLIDAY PAY INFORMATION
   01 ( ) Voluntary Leaving (Quit)                            The employee received or will receive:
   02 ( ) Discharge (Fired)                                     ( ) Vacation                $ __________ week(s) ______
   03 ( ) Lack of Work (R.I.F.)                                 ( ) Severance/Dismissal $ __________ week(s) ______
   04 ( ) Leave of Absence                                      ( ) Bonus                   $ __________ week(s) ______
   05 ( ) Not Physically Able to Work                           ( ) Holiday Pay             $ __________ week(s) ______
   06 ( ) School Employee Contract
   07 ( ) Refused Other Suitable Work                          LUMP SUM           ( ) Vacation ( ) Accrued Leave
   08 ( ) Labor Dispute                                                 ( ) Severance/Dismissal Pay      ( ) Bonus
   09 ( ) Retirement, Pension                                                       ( ) Holiday Pay ( ) Other Remuneration
   10 ( ) Other (Please Explain)                                                    covers a period of __________week(s).


EXPLANATION:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________


I certify that the worker whose name and social security number appear above has been separated from work and that the above
information is true and correct. I further certify that the individual has been handed or mailed a copy of this notice.


8. ____________________________________            9. _______________________             10. ___________________________
           Employer Name                                  Phone - Area Code & No.                       Employer Acct. No.


11. ___________________________________________________________________12. ___________________________
          Address       Street/Box                 City                   State                                   Zip Code


13. ___________________________________ 14. ___________________________ 15. __________________________
                Signature                                                   Title                                     Date
_______________________________________________________________________________________________________
FILL OUT IN TRIPLICATE. MAIL OR FAX (225) 346-6068 ORIGINAL TO - Administrator, Louisiana Workforce
Commission , Post Office Box 91253, Baton Rouge, LA, 70821-9253 WITHIN 72 HOURS after separation. Give a copy of
this form and a copy of the “Instructions to the Worker” to the employee within 72 hours, and retain a copy for your files.

Failure to submit this notice within the specified time limits may forfeit your right to appeal. It must be submitted within
72 hours after the worker’s separation from employ.
                  INSTRUCTIONS TO EMPLOYER FOR PREPARATION OF
                   SEPARATION NOTICE ALLEGING DISQUALIFICATION

         A Separation Notice Alleging Disqualification should be made out in triplicate for each worker who
leaves your employ without good cause connected with his work, is discharged for misconduct connected
with his work, or is unemployed because of a labor dispute.

       Mail or Fax (225) 346-6068 an original to the Administrator, Louisiana Workforce Commission, Post Office
Box 91253, Baton Rouge, Louisiana 70821-9253 within 72 hours after employee has been separated from work.

        Give a duplicate copy to the worker along with the “Instructions To The Worker” and the Worker’s
Claim Information, Form LWC 87W, or if delivery is impossible, mail to his last known address within 72
hours.

        Keep a triplicate in your files for reference.

Item 1 Enter here the worker’ s full name as it appears on your records. If it is different from that on the
       Social Security card, report both names.

Item 2 Enter worker’ s Social Security Number. If it is known to you that he has more than one number,
       enter all numbers.

Item 3 Enter the date the worker was separated from your employ.

Item 4 Enter the date the worker was hired.

Item 5 Enter the date the worker last worked.

Item 6 Check the reason for separation and explain in detail in space provided.
       01      Voluntary Leaving: give the detailed reason for leaving so that it can be determined whether
               or not a disqualification for leaving without good cause attributable to a substantial change
               with the employment should be assessed.
       02      Discharge, Misconduct: give the detailed reason for discharge so that the information can
               be used in determining whether or not a disqualification should be assessed for misconduct
               connected with the work.
       03      Lack of Work (RIF)
       04      Leave of Absence: give complete details as to the reason for the leave and the time period
               involved.
       05      Not Physically Able to Work: give all details known to you relative to the worker’ s illness or
               injury.
       06      School Employee: give complete information relative to reason for the separation and
               whether or not the worker had a contract or a reasonable assurance of returning.
       07      Refused Other Suitable Work: give detailed information relative to the new work offered,
               such as, salary, hours, job conditions, location, etc.
       08      Labor Dispute: give details of labor dispute so that the information can be used in
               determining whether or not the worker is disqualified for benefits due to participation in the
               dispute.
       09      Retirement: give the detailed reason for retirement, whether voluntary or compulsory, exact
               amount of pension before deductions, and whether company contributed, employee
               contributed or a combination of employer/employee contributions.
       10      Other: enter here any other reason not enumerated above which might disqualify the
               worker. Give full explanation.

Items 7 - 12    Complete as indicated on the form. Report gross dollar amounts.

Items 13 - 15    This notice should be signed by an officer or employee authorized to assume responsibility
                 for the information and his title or position. This notice should be dated as of the date it is
                 handed or mailed to the worker and mailed or faxed (225) 346-6068 to the Administrator,
                 Louisiana Workforce Commission, Post Office Box 91253, Baton Rouge, LA 70821-9253.
                               INSTRUCTIONS TO THE WORKER

        Having become unemployed, you should go to an office of the Louisiana Workforce Commission most
convenient to you and register for work. If you intend to file a claim for benefits, you may do so at the same
time. Under the Louisiana Employment Security Law, you may be disqualified for benefits, if it is determined
that:

                You left your work without good cause attributable to a substantial
                change with your employment, or

                You were discharged for misconduct connected with your work, or

                You failed to accept suitable work when offered or to apply for available
                suitable work, when so directed by the Administrator or the employment
                office, or

                You were taking part in a labor dispute in the establishment in which you
                were employed, or you were seeking unemployment compensation benefits
                under any other State or Federal Law.

         It is important for you to register for work immediately even though you may be temporarily
disqualified for benefits.

        In deciding whether you are disqualified, the Louisiana Workforce Commission will consider the
statements made by your employer on Form LWC 77, Separation Notice, concerning the reason for your
separation and the statements you make when you file your claim for benefits at the office of the Louisiana
Workforce Commission. If you do not agree with the reasons for leaving your job as given on the Form LWC
77, Separation Notice, state reason for leaving your job to the representative at the office of the Louisiana
Workforce Commission.

        NOTE: It is not necessary to EMPLOY any one to help you collect benefits. Any representative of
the Louisiana Workforce Commission will advise you and help you with your claim.

        REGISTER at once at the most convenient office of the Louisiana Workforce Commission .